Personal and Emergency Contact Information

Fields marked with an * are required

Personal Information

Non Clarke Email Address *

Student Type*

First Name *

Middle Name

Last Name *

Birthdate *

Cell Phone *

Are you a commuter? *

Commuter

Live on Campus

Local Address *

Country
Street
City
Region
Postal Code

Permanent Address *

Country
Street
City
Region
Postal Code

Personal Information

Height *

Weight *

Hair Color *

Gender *

Race/Ethnicity Colleges and universities are asked by many groups, including the federal government, accrediting associations, college guides, and newspapers, to describe the ethnic/racial backgrounds of their students and employees. In order to respond to these requests, we ask you to respond to the following two questions

Are you a Hispanic or Latino ?

Yes

No

Regardless of your answer to the prior question, please check one or more of the following groups in which you consider yourself to be a member:

Religion

Married *

Yes

No

Emergency Contact Information

Please list your emergency contact(s). This data will be used to provide contact information in the event of an emergency. Please list the contacts in the order you want them to be notified if an emergency arises. Clarke University will call those in the order listed until a person is reached.

Relationship *

First Name *

Last Name *

Phone *

Email Address *

Should this person be contacted in the event of an emergency? *

Yes

No

In case of serious illness or accident, do you want a priest/clergyman to be called? *

Yes

No

Add another emergency contact? *

Yes

No

Relationship *

First Name *

Last Name *

Phone *

Email Address *

Should this person be contacted in the event of an emergency? *

Yes

No

In case of serious illness or accident, do you want a priest/clergyman to be called? *

Yes

No

Add another parent/guardian? *

Yes

No

Relationship *

First Name *

Last Name *

Phone *

Email Address *

Should this person be contacted in the event of an emergency? *

Yes

No

In case of serious illness or accident, do you want a priest/clergyman to be called? *

Yes

No

Medical Information

List any Medications to which you are allergic - separated by commas *

List any chronic illnesses - separated by commas *

List any medication(s) you take on a regular basis - separated by commas *

Insurance Company *

Policy Number *

Thank you for providing this information. If you need to make any changes or updates, please contact the Student Life Office at (563)588-6313